[Blood transfusion incident analysis by ALARM method].
The hospital risk management department is firstly involved in the methodological analysis of grade zero transfusion incidents. The system is based on a subsequent analysis process in compliance with the ongoing requirements of the Haute Autorité de santé (HAS) for a reactive approach to risk, allowing to identify failures and start the appropriate preventive and corrective measures. The use of the association of litigation and risk management method makes easier the grade zero analysis and brings to light the team or institutional, organizational, temporal, individual factors representative of undesirable effects. Two main factors come out again from this analysis, the absence of the identification bracelet coupled with a disrespect of transfusion procedures in force. The whole institution must be concerned by these improvement actions. Health teams should overcome difficulties to be totally involved in such a process. Human factors' recognition, establishment of clear and effective communication between individuals and information sharing should provide optimum quality care services which are safe and free of unnecessary risks.
Lassale
B
B
Service d'hémovigilance, Assistance publique-Hôpitaux de Marseille, hopitaux Sud, Marseille, France. bernard.lassale@ap-hm.fr
Courtinat
C
C
D001788:Blood Grouping and Crossmatching; D016063:Blood Loss, Surgical; D001919:Bradycardia / Q000209:etiology; D003221:Confusion; D017707:Erythrocyte Transfusion; D005602:France; D006801:Humans; D007431:Intraoperative Complications / Q000209:etiology; D019300:Medical Errors / Q000517:prevention & control; D010355:Patient Identification Systems / Q000379:methods / Q000458:organization & administration; D055656:Prescriptions; D011785:Quality Assurance, Health Care / Q000458:organization & administration*; D011786:Quality Control; D012308:Risk Management / Q000331:legislation & jurisprudence / Q000458:organization & administration*; D013117:Spinal Cord Compression / Q000601:surgery; D065227:Transfusion Reaction